Impact of ERAS compliance on the delay between surgery and adjuvant chemotherapy in hepatobiliary and pancreatic malignancies

Abstract

Background Multidisciplinary approach with adjuvant chemotherapy is the key element to provide optimal outcomes in pancreas and liver malignancies. However, post-operative complications may increase the interval between surgery and chemotherapy with negative oncologic effects. Hypothesis and study aim The aim of the study was to analyse whether compliance to Enhanced Recovery After Surgery (ERAS) pathway was associated with decreased interval to adjuvant chemotherapy. Methods Retrospective analysis of all consecutive ERAS patients with surgery for hepatobiliary or pancreatic malignancies at the University Hospital of Lausanne between 2012 and 2016. Multivariate analysis was performed to assess the impact of ERAS compliance on time to chemotherapy. Results A total of 133 patients with adjuvant chemotherapy were included (n = 44 liver and n = 89 pancreatic cancer). Median compliance to ERAS was 61% (IQR 55–67) for the study population, and median delay to chemotherapy was 49 days (IQR 39-61). Overall, compliance ≥ 67% to ERAS induced a significant reduction in the interval between surgery and chemotherapy for young patients (< 65 years old) with or without severe comorbidities (reduction of 22 and 10 days, respectively). High compliance in young ASA3 patients with liver colorectal metastases was associated with an increase of 481 days of DFS. Conclusions ERAS compliance ≥ 67% tends to be associated with a reduction in the delay to adjuvant chemotherapy for young patients with hepatobiliary and pancreatic malignancies. More prospective studies with strict adhesion to the ERAS protocol are needed to confirm these results.

Oncologic and long-term outcomes of enhanced recovery after surgery in cancer surgeries — a systematic review

“…The outcomes and findings of the included studies are displayed in Table 3 . Seventeen studies described oncologic outcomes [ 11 , 12 , 16 – 23 , 25 , 28 – 31 , 33 , 35 ], and 20 studies described long-term outcomes [ 10 – 16 , 22 – 34 ].…”

“…Half of the studies showed no differences in OS between high and low adherence [ 16 , 22 , 26 ], and half showed improvements in OS by high adherence to ERAS [ 23 , 24 , 34 ]. Two studies reported DFS [ 16 , 25 ]; one showed that high adherence to ERAS could improve 3-year DFS [ 25 ], and the other did not find any difference [ 16 ]. One study showed that high adherence to ERAS could improve 5-year CSS [ 23 ], 2 studies reported that high adherence to ERAS had no effect on 3-year metastasis or 5-year recurrence [ 22 , 23 ], and 1 study showed that high adherence to ERAS reduced the interval from surgery to RIOT [ 25 ].…”

Systematic review and meta-analysis of the impact of deviations from a clinical pathway on outcomes following pancreatoduodenectomy

“…Within these 11 studies[ 6 , 10 , 16 - 24 ], a total of 1852 patients underwent PD and were managed according to their respective institutional clinical pathways. Eight studies[ 6 , 10 , 17 - 19 , 22 - 24 ] stratified patients according to a specific, albeit arbitrary, level of compliance and compared their immediate post-operative outcomes. The characteristics, methodology and conclusions of the included studies are provided in Tables 1 and 2 .…”

“…The 11 studies analyzed (Table 1 ) included 6 prospective[ 10 , 16 , 17 , 21 - 23 ] and 5 retro-spective[ 6 , 18 - 20 , 24 ] studies all published since 2014. There were 2 publications from India[ 11 , 23 ], Canada[ 18 , 20 ] and Italy[ 16 , 22 ], and 1 each from Switzerland[ 19 ], Israel[ 21 ], Sweden[ 24 ] and Greece[ 24 ], all from single centers, with 1 publication from multiple centers in Europe[ 10 ]. The median overall compliance to all components of the clinical pathway was 65.7% (IQR: 62.7%-72.3%) with median compliance to post-operative parameters of the clinical pathway being 44% (IQR: 34.5%-52.25%) in the 4 included studies that reported the values.…”

“…In four[ 10 , 16 , 22 , 23 ] of the included studies, the teams employed a pre-, intra- and post-operative pathway, while in 6 other studies[ 6 , 17 , 18 , 20 , 21 , 24 ] the teams focused on a post-operative clinical pathway alone. One study did not specify their protocol details[ 19 ]. Not surprisingly, overall compliance to the pathways remained relatively high 65.7% (IQR: 62.7%-72.3%).…”